The Limes is a care home that provides support and accommodation for up to 97 older people, some of whom may be living with dementia. On the day of the inspection there were 97 people living at the home, including one person who was having respite care. Most of the accommodation is on the ground floor although the residential area has two floors. There is a passenger lift to access the first floor. There are two distinct areas at the home, including one that provides support for people who are living with dementia, and these are staffed separately. There are various communal areas and safe garden where people can spend the day.

At the last inspection the service was rated as Good overall. At this inspection we found that the service remained Good.

There were sufficient numbers of staff employed to make sure people received the support they needed, and those staff had been safely recruited.

Staff received appropriate training that gave them the knowledge and skills they required to carry out their roles. This included training on the administration of medicines and on how to protect people from the risk of harm.

People were supported to have choice and control over their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Staff were kind and caring, and they respected people’s privacy and dignity.

Care planning described the person and the level of support they required. Care plans were reviewed regularly to ensure they remained an accurate record of the person and their day to day needs.

People and their relatives told us they were aware of how to express concerns or make complaints and we saw any complaints made had been thoroughly investigated and responded to.

The registered manager carried out audits to ensure people were receiving the care and support they required. People were also given the opportunity to share their views about the service provided.

The feedback we received and our observations on the day of the inspection demonstrated that the home was well managed.

Further information is in the detailed findings below

We carried out an unannounced comprehensive inspection of this service on 11 and 12 August 2015 and we found a breach of legal requirement in respect of training for staff on behaviours that challenge the service. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to this breach. We undertook this focused inspection to check that they had followed their plan and to check that they now met legal requirements. This report covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the 'all reports' link for The Limes House on our website at www.cqc.org.uk

The home is registered to provide accommodation and care for up to 97 older people, including people who are living with dementia. There were 96 people living at the home on the day of this inspection, including seven people who were having respite care. The home is situated in Driffield, in the East Riding of Yorkshire. There is an area of the home where people who are living with dementia are accommodated and another area for older people; these are staffed separately. All accommodation is on the ground floor and there are enclosed courtyards where people can access outdoor areas safely. People have single bedrooms with en-suite facilities, and there are also communal bathing and showering facilities.

The registered provider is required to have a registered manager in post and on the day of the inspection there was a manager who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we saw that staff had completed training on non-abusive psychological and physical intervention (NAPPI). This training aims to equip staff with the skills to safely manage people who display behaviours that might challenge the service. We saw that this training had been incorporated into staff induction training. Staff had received other training to help them to carry out their roles effectively, and they received support from a senior manager in supervision and appraisal meetings.

The service was working within the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). We saw that people’s capacity to make decisions had been assessed and when people lacked the capacity to make decisions for themselves, best interest decisions had been made on their behalf and recorded.

People’s nutritional needs were assessed and their special diets were catered for. People received support from health care professionals when required and we found that staff followed any advice and guidance they were given.

The area of the home where people living with dementia were accommodated had been refurbished. This provided high quality accommodation that included space for people to move around freely, signage to help people find their way around the premises and various ways of providing orientation for people. The dining room was in the style of a cafeteria which provided clear prompts for people to indicate this was where food and drink was served.

We carried out an unannounced comprehensive inspection of this service on 4 December 2014. A breach of legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach in respect of poor recruitment and selection practices.

We undertook this focused inspection to check that they had followed their plan and to check that they now met legal requirements. This report covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Limes on our website at www.cqc.org.uk

The Limes is a care home for older people that is located in Driffield, a market town in the East Riding of Yorkshire. It can accommodate up to 85 older people, including those with a dementia related condition. It has a separate dementia unit for people who are living with dementia. The home is close to local amenities and transport routes.

The registered provider is required to have a registered manager in post and on the day of the inspection there was a manager registered with the Care Quality Commission (CQC); they had been registered since 21 October 2013. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the inspection on 9 June 2015 we found that the registered manager had carried out the improvements that were recorded in their action plan. There were robust recruitment and selection policies and procedures in place at the home and these had been followed each time a new member of staff had been employed.

This inspection took place on 4 December 2014 and was unannounced. We previously visited the service on 14 May 2014 and on that occasion found that the provider met the regulations we assessed.

The service is registered to provide personal care and accommodation for 85 older people and there were 83 people living at the home on the day of the inspection. The home is situated close to the town centre of Driffield, in the East Riding of Yorkshire and is located within its own grounds. The Limes has a residential unit and a dedicated dementia unit that accommodates 33 people who are living with dementia. The units are staffed separately.

The provider is required to have a registered manager in post and on the day of the inspection there was a manager registered with the Care Quality Commission (CQC); they had been registered since 1 August 2013. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us that they felt safe living at the home. Staff had completed training on safeguarding adults from abuse and were able to describe to us the action they would take if they had concerns about someone’s safety. They said that they were confident all staff would recognise and report any incidents or allegations of abuse.

People who used the service, visitors and health care professionals told us that staff were effective and had the skills they needed to carry out their roles. Records evidenced that staff took part in various training opportunities that would equip them to carry out their roles effectively.

The registered manager was aware of guidance in respect of providing a dementia friendly environment and progress had been made towards achieving this. Staff had undertaken training on dementia awareness and the Mental Capacity Act 2005 (MCA). This helped them to understand the care needs of people with a dementia related condition.

We saw that there were sufficient numbers of staff on duty to meet the needs of people who lived at the home. However, staff had not always been recruited following the home’s policies and procedures to ensure that only people considered suitable to work with vulnerable people had been employed. This was a breach of Regulation 21 of the Health and Social Care Act 2008. You can see what action we told the provider to take at the back of the full version of the report.

People’s nutritional needs had been assessed and people told us that they were satisfied with the meals provided by the home. We found that medicines were safely managed.

We observed good interactions between people who lived at the home and staff on the day of the inspection. People told us that staff were caring and this was supported by the visitors we spoke with.

People’s comments and complaints were responded to appropriately and there were systems in place to seek feedback from people and their relatives about the service provided.

People who lived at the home, visitors and staff told us that the home was well managed, although a small number of staff told us that they did not always feel supported or listened to. The registered provider had appointed a staff advocate and it was hoped that this would give staff another person who they could discuss any concerns with.

Summary

We carried out this inspection to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were treated with respect and dignity and we observed caring and compassionate care by the staff. People told us they felt safe. People had their own care file and these contained an assessment of needs for example; mobility, eating and drinking, mental health, skin care, social activity, monitoring charts and contact with other professionals. This contained information about the way each person should be supported and cared for. Additional information included risk assessments to ensure people remained safe from harm.

We looked at safeguarding referral records that were recorded to ensure people who used the service were kept safe from harm. We found the records accurate and complete and when required, a notification was sent to us at the Care Quality Commission (CQC). This meant that people were protected from the risk of harm.

A visiting relative told us, “My relative was admitted here urgently and then went home after a while but she wanted to come back here. I have never overheard or seen anything negative from the staff, they are all so friendly.”

We looked at medicine administration records (MAR) documentation and found these to be accurate, precise and transcribed in a clear and consistent manner. People’s MAR documentation also included a photo of the person to reduce the risk of inaccuracies.

Is the service effective?

We observed a number of care and support activities that staff undertook. We saw that staff appeared calm, very supportive and compassionate with people’s needs. Staff were able to describe people’s needs and how these should be best met. We saw that daily notes detailed what care the person received.

We spoke with people who used the service. Comments included, “Staff know what they are doing and they ask you how you are and if you are happy. I do feel safe here”, “It’s nice here. The staff are very kind and I have a nice room” and “I decide whether I want to get up, it’s up to me.”

Is the service caring?

Staff we spoke with were clear and precise about their role. One staff member we spoke with told us, “We review peoples care plans with them regularly and discuss their ‘day to day’ lives with them. We have a six weekly review too which goes into much more detail.” Records we looked at corroborated this.

We spoke with a visiting health care professional and they told us, “I visit quite often and the service always appears well organised and they know we are coming. Paperwork is always well prepared and they are very on the ball. Staff are very caring and they are accommodating and have helped with urgent admissions in the past when needed.”

Is the service responsive?

We observed a game of cards being played by five people and they appeared to have enjoyed the session. We observed some people who used the service choosing their favourite book from the mobile library that attended the service. We also observed the lunchtime session which was well organised and staff were clear about their roles in supporting people that needed it.

We spoke with visiting relatives of people that used the service and they told us, “The care is very good here and the owners are often available to answer any questions we have”, “My relative always looks well and staff deal with accidents promptly and respectfully” and “Staff handle people’s good and bad moods very well, without being patronising.”

People knew how to make a complaint if they were unhappy. We looked at how these complaints had been dealt with, and found that the response had been open, thorough, and timely. People were therefore assured that complaints were investigated and action was taken as necessary.

Is the service well-led?

The service had an effective quality assurance system in place and records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

We saw records that showed the service had completed a ‘residents and relatives’ survey in July 2013 and another survey had been completed in January 2014.

We saw responses from people who used the service, their relatives and other professionals. We saw that survey responses were received from 29 people who used the service, 14 relatives and nine professionals. An analysis of results was completed and a ‘survey action plan’ was completed to ensure any concerns raised was captured and acted on.

We saw records of regular meetings had taken place for different staff groups for example; care day staff, care night staff, seniors, domestic and laundry staff. Records we looked at confirmed meetings were well attended and discussed topics for example; personal care, equality and diversity, care plans, keyworker notes, teamwork, and cleanliness.

People told us that staff discussed their care and treatment with them and that they were involved in the reviews of their care. One visitor said “My parent has a care plan and it has been discussed with both of us”.

We found people were being looked after by friendly, supportive staff within a warm and homely environment. Care was risk assessed and records were up to date. Relatives told us that communication between the staff and people was “Brilliant”.

People who used the service were supported to take part in a range of activities both within the service and out in the community. We spoke with people who were taking part in activities and they told us “There are plenty of things for us to do here”, “We are spoilt for choice” and “The staff always have time to chat with you”.

Infection control systems within the service were looked at. These were monitored regularly by the provider. People told us “The home is immaculate, our bedrooms are cleaned daily and the staff keep everything spotless.”

We saw the service had an effective recruitment policy and procedure, which ensured staff working in the home had the right skills and qualifications to meet people’s needs.

The provider had an effective quality assurance system in place and people’s views and opinions of the service were listened to and acted on where necessary. One relative said “The home is like a five star hotel, I cannot fault it”.

We spoke with people who used the service. They were all very happy with their care. They told us that they were given support when needed, but were also given the chance to be as independent as possible.

People said “The care staff are lovely, they look after us very well and the food is nice with plenty of choices.” One relative told us “The care here is very good and people are happy and safe.”

Sufficient staff were on duty to meet the needs of people who used the service. Staff received training to ensure that their skills and knowledge remained up to date and the manager regularly supervised their work practice.

We found that although care needs were being met the care documentation was not detailed especially around physical and mental health needs. We also had some minor concerns about infection prevention and control practices, which were discussed with the provider and manager on the day of our visit.

People we spoke with told us they were able to come and go as they pleased and there were no restriction placed on their movements. They also told us they had been involved with resident meetings and they could influence what happened in the home.

They also told us the care staff were very kind and caring, one person said “They just can’t do enough for you”; “They are always there when you need them.”

People told us they knew who they could complain to and were satisfied any concerns would be taken seriously.

We carried out this inspection on 11 and 12 August 2015 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the registered provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

This was an unannounced inspection which meant that the staff and registered provider did not know that we would be visiting. We commenced the inspection at 7.00 pm on 11 August 2015 in response to some information of concern we needed to follow up. This provided the opportunity to observe practices and talk to staff across both day and night shifts.

The last inspection of the home, which was carried out on 9 June 2015, was a follow up inspection to check whether the registered manager had made the necessary improvements to the services recruitment and selection procedures. We found that while improvements had been made we did not revise the rating for this key question; to improve the rating to ‘Good’ would require a longer term track record of consistent good practice.

The service is registered to provide personal care and accommodation for 85 older people and there were 83 people living at the home on the day of the inspection. The home is situated close to the town centre of Driffield, in the East Riding of Yorkshire and is located within its own grounds. The Limes has a residential unit and a dedicated dementia unit that accommodates 33 people who are living with dementia. The units are staffed separately.

The provider is required to have a registered manager in post and on the day of the inspection there was a manager registered with the Care Quality Commission (CQC); they had been registered since 1 August 2013. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like providers, they are ‘registered persons’.

Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff told us they received training relevant to their job and training records supported this. However, staff also told us that at times they have to manage people who display behaviours that challenge others. Staff told us they had not received training in physical interventions such as safe hand holds or break away techniques. This was a breach of a regulation. You can see what action we told the provider to take at the back of the full version of the report.

Staff had completed training on safeguarding adults from abuse and were able to describe to us the action they would take if they had concerns about someone’s safety or had witnessed abuse. Staff told us they had no concerns regarding any of the practice they had observed by their colleagues.

People had their health and social care needs assessed and plans of care were developed to guide staff in how to support people. The plans of care were individualised to include preferences, likes and dislikes. People who used the service received additional care and treatment from health based professionals in the community.

We saw that there were sufficient numbers of staff on duty to meet the needs of people who lived at the home. However we were told that there were times when sickness was not always covered. The home had taken steps to alleviate this concern and planned to increase staffing levels.

Incident and accidents in the home were accurately recorded, monitored monthly and appropriate action plans were put in place to try to minimise any reoccurrence.

Management and senior care staff had received Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) training and understood the requirements of the Act which meant they were working within the law to support people who may lack capacity to make their own decisions. However the service needs to ensure that MCA guidelines are fully followed in relation to the recording of best interest decisions. We made a recommendation about the recording of best interest meetings.

The registered manager was aware of guidance in respect of providing a dementia friendly environment and progress had been made towards achieving this. Staff had undertaken training on dementia awareness. This helped them to understand the care needs of people with a dementia related condition.

Following the last inspection on 9 June 2015 we saw that staff continued to be recruited in accordance with the homes policies and procedures. This meant that people were protected from staff that may be unsuitable to work with vulnerable adults or children.

Care plans were well written and updated on a regular basis. This ensured they were reflective of the needs of the people they were written for and that staff had access to the most relevant information.

People’s nutritional needs had been assessed and responded to. People told us that they were satisfied with the meals provided by the home. We saw people who required support with eating received this in a dignified manner.

We saw the recording of some documentation including food, fluid and repositioning charts were poorly completed and in some instances charts were completed retrospectively. We made a recommendation about the need for accurate recording on documentation.

We found that medicines were safely managed and administered, and people received their medication on time. We have made a recommendation about the use of ‘as and when required’ (PRN) medication.

We observed good interactions between people who used the service and the care staff throughout the inspection. People told us that staff were caring and this view was supported by the visitors we spoke with.

People’s comments and complaints were responded to appropriately and there were systems in place to seek feedback from people and their relatives about the service provided. However the home acknowledged that there had been some delay in providing the results of the staff survey to staff members.

People who lived at the home, visitors and staff told us that the home was well managed. All of the staff apart form one told us they found the homes manager approachable and that they felt confident to raise concerns and were well supported.